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Pregnancy at Risk: Pregestational Onset

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Title: Pregnancy at Risk: Pregestational Onset


1
Pregnancy at Risk Pregestational Onset
2
Alcohol Use in Pregnancy
  • Maternal effects
  • Malnutrition
  • Bone-marrow suppression
  • Increased incidence of infections
  • Liver disease
  • Neonatal effects
  • Fetal alcohol spectrum disorders (FASD)

3
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4
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5
Cocaine Use in Pregnancy Maternal Effects
  • Seizures and hallucinations
  • Pulmonary edema
  • Respiratory failure
  • Cardiac problems
  • Spontaneous first trimester abortion, abruptio
    placentae, intrauterine growth restriction
    (IUGR), preterm birth, and stillbirth

6
Cocaine Use in Pregnancy Fetal Effects
  • Decreased birth weight and head circumference
  • Feeding difficulties
  • Neonatal effects from breast milk
  • Extreme irritability
  • Vomiting and diarrhea
  • Dilated pupils and apnea

7
Heroin Use in Pregnancy
  • Maternal effects
  • Poor nutrition and iron-deficiency anemia
  • Preeclampsia-eclampsia
  • Breech position
  • Abnormal placental implantation
  • Abruptio placentae
  • Preterm labor

8
Heroin Use in Pregnancy (contd)
  • Maternal effects
  • Premature rupture of the membranes (PROM)
  • Meconium staining
  • Higher incidence of STIs and HIV
  • Fetal effects
  • IUGR
  • Withdrawal symptoms after birth

9
Substance Use in Pregnancy Maternal Effects
  • Marijuana difficult to evaluate, no known
    teratogenic effects
  • PCP - maternal overdose or a psychotic response
  • MDMA (Ecstasy) - long-term impaired memory and
    learning

10
Pathology of Diabetes Mellitus (DM)
  • Endocrine disorder of carbohydrate metabolism
  • Results from inadequate production or utilization
    of insulin
  • Cellular and extracellular dehydration
  • Breakdown of fats and proteins for energy

11
Gestational Diabetes (GDM)
  • Carbohydrate intolerance of variable severity
  • Causes
  • An unidentified preexistent disease
  • The effect of pregnancy on a compensated
    metabolic abnormality
  • A consequence of altered metabolism from changing
    hormonal levels

12
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13
Effect of Pregnancy on Carbohydrate Metabolism
  • Early pregnancy
  • Increased insulin production and tissue
    sensitivity
  • Second half of pregnancy
  • Increased peripheral resistance to insulin

14
Maternal Risks with DM
  • Hydramnios
  • Preeclampsia-eclampsia
  • Ketoacidosis
  • Dystocia
  • Increased susceptibility to infections

15
Fetal and Neonatal Risks with DM
  • Perinatal mortality
  • Congenital anomalies
  • Macrosomia
  • IUGR
  • RDS
  • Polycythemia

16
Fetal and Neonatal Risks with DM (contd)
  • Hyperbilirubinemia
  • Hypocalcemia

17
Screening for DM in Pregnancy
  • Assess risk at first visit
  • Low risk - screen at 24 to 28 weeks
  • High risk - screen as early as feasible

18
Risk Factors
  • Age over 40
  • Family history of diabetes in a first-degree
    relative
  • Prior macrosomic, malformed, or stillborn infant
  • Obesity
  • Hypertension
  • Glucosuria

19
Screening Tests
  • One-hour glucose tolerance test
  • Level greater than 130-140 mg/dl requires further
    testing
  • 3-hour glucose tolerance test
  • GDM diagnosed if 2 levels are exceeded

20
Treatment Goals
  • Maintain a physiologic equilibrium of insulin
    availability and glucose utilization
  • Ensure an optimally healthy mother and newborn
  • Treatment
  • Diet therapy and exercise
  • Glucose monitoring
  • Insulin therapy

21
Fetal Assessment
  • AFP
  • Fetal activity monitoring
  • NST
  • Biophysical profile
  • Ultrasound

22
Nursing Management
  • Assessment of glucose
  • Nutrition counseling
  • Education about the disease process and
    management
  • Education about glucose monitoring and insulin
    administration
  • Assessment of the fetus
  • Support

23
Iron-deficiency Anemia
  • Maternal complications
  • Susceptible to infection
  • May tire easily
  • Increased chance of preeclampsia and postpartal
    hemorrhage
  • Tolerates poorly even minimal blood loss during
    birth

24
Iron-deficiency Anemia (contd)
  • Fetal complications
  • Low birth weight
  • Prematurity
  • Stillbirth
  • Neonatal death

25
Iron Deficiency Anemia (contd)
  • Prevention and treatment
  • Prevention - at least 27 mg of iron daily
  • Treatment - 60-120 mg of iron daily

26
Folate Deficiency
  • Maternal complications
  • Nausea, vomiting, and anorexia
  • Fetal complications
  • Neural tube defects
  • Prevention - 4 mg folic acid daily
  • Treatment - 1 mg folic acid daily plus iron
    supplements

27
Folate Deficiency
  • Maternal complications
  • Nausea, vomiting, and anorexia
  • Fetal complications
  • Neural tube defects
  • Prevention - 4 mg folic acid daily
  • Treatment - 1 mg folic acid daily plus iron
    supplements

28
Sickle Cell Anemia
  • Maternal complications
  • Vaso-occlusive crisis
  • Infections
  • Congestive heart failure
  • Renal failure

29
Sickle Cell Anemia (contd)
  • Fetal complications include fetal death,
    prematurity, and IUGR.
  • Treatment
  • Folic acid
  • Prompt treatment of infections
  • Prompt treatment of vaso-occlusive crisis

30
Thalassemia
  • Treatment
  • Folic acid
  • Transfusion
  • Chelation

31
HIV in Pregnancy
  • Asymptomatic women - pregnancy has no effect
  • Symptomatic with low CD4 count - pregnancy
    accelerates the disease
  • Zidovudine (ZDV) therapy diminishes risk of
    transmission to fetus
  • Transmitted through breast milk
  • Half of all neonatal infections occurs during
    labor and birth

32
HIV in Pregnancy Maternal Risks
  • Intrapartal or postpartal hemorrhage
  • Postpartal infection
  • Poor wound healing
  • Infections of the genitourinary tract

33
HIV Effects on Fetus
  • Infants will often have a positive antibody titer
  • Infected infants are usually asymptomatic but are
    likely to be
  • Premature
  • Low birth weight
  • Small for gestational age (SGA)

34
Treatment During Pregnancy
  • Counsel about implications of diagnosis on
    pregnancy
  • Antiretroviral therapy
  • Fetal testing
  • Cesarean birth

35
Cardiac Disorders in Pregnancy
  • Congenital heart disease
  • Marfan syndrome
  • Peripartum cardiomyopathy
  • Eisenmenger syndrome
  • Mitral valve prolapse

36
Less Common Medical Conditions in Pregnancy
  • Rheumatoid arthritis
  • Epilepsy
  • Hepatitis B
  • Hyperthyroidism
  • Hypothyroidism
  • Maternal phenylketonuria

37
Less Common Medical Conditions in Pregnancy
(contd)
  • Multiple sclerosis
  • Systemic lupus erythematosus
  • Tuberculosis

38
Pregnancy at Risk Gestational Onset
39
Spontaneous Abortion
  • Threatened abortion
  • Imminent abortion
  • Incomplete abortion
  • Complete abortion

40
Types of spontaneous abortion. A Threatened The
cervix is not dilated, and the placenta is still
attached to the uterine wall, but some bleeding
occurs.
41
B Imminent. The placenta has separated from the
uterine wall, the cervix has dilated, and the
amount of bleeding has increased.
42
C Incomplete. The embryo/fetus has passed out of
the uterus however, the placenta remains.
43
Spontaneous Abortion (contd)
  • Missed abortion
  • Recurrent pregnancy loss
  • Septic abortion

44
Spontaneous Abortion Treatment
  • Bed rest
  • Abstinence from coitus
  • DC or suction evacuation
  • Rh immune globulin

45
Spontaneous Abortion Nursing Care
  • Assess the amount and appearance of any vaginal
    bleeding
  • Monitor the womans vital signs and degree of
    discomfort
  • Assess need for Rh immune globulin.
  • Assess fetal heart rate
  • Assess the responses and coping of the woman and
    her family

46
Ectopic Pregnancy Risk Factors
  • Tubal damage
  • Previous pelvic or tubal surgery
  • Endometriosis
  • Previous ectopic pregnancy
  • Presence of an IUD
  • High levels of progesterone

47
Ectopic Pregnancy Risk Factors (contd)
  • Congenital anomalies of the tube
  • Use of ovulation-inducing drugs
  • Primary infertility
  • Smoking
  • Advanced maternal age

48
Ectopic Pregnancy Treatment
  • Methotrexate
  • Surgery

49
Various implantation sites in ectopic pregnancy.
The most common site is within the fallopian
tube, hence the name tubal pregnancy
50
Ectopic Pregnancy Nursing Care
  • Assess the appearance and amount of vaginal
    bleeding
  • Monitors vital signs
  • Assess the womans emotional status and coping
    abilities
  • Evaluate the couples informational needs.
  • Provide post-operative care

51
Gestational Trophoblastic Disease Symptoms
  • Vaginal bleeding
  • Anemia
  • Passing of hydropic vesicles
  • Uterine enlargement greater than expected for
    gestational age
  • Absence of fetal heart sounds
  • Elevated hCG

52
Gestational Trophoblastic Disease Symptoms
  • Low levels of MSAFP
  • Hyperemesis gravidarum
  • Preeclampsia

53
Gestational Trophoblastic Disease Treatment
  • DC
  • Possible hysterectomy
  • Careful follow-up

54
Hydatidiform mole. A common sign is vaginal
bleeding, often brownish (the characteristic
prune juice appearance) but sometimes bright
red. In this figure, some of the hydropic vessels
are being passed. This occurrence is diagnostic
for hydatidiform mole.
55
Gestational Trophoblastic Disease Nursing Care
  • Monitor vital signs
  • Monitor vaginal bleeding
  • Assess abdominal pain
  • Assess the womans emotional state and coping
    ability

56
Bleeding Disorders
  • Placenta previa - placenta is improperly
    implanted in the lower uterine segment
  • Abruptio placentae - premature separation of a
    normally implanted placenta from the uterine wall

57
Cervical Incompetence Treatment
  • Serial cervical ultrasound assessments
  • Bed rest
  • Progesterone supplementation
  • Antibiotics
  • Anti-inflammatory drugs
  • Cerclage procedures

58
A cerclage or purse-string suture is inserted in
the cervix to prevent preterm cervical dilatation
and pregnancy loss. After placement, the string
is tightened and secured anteriorly.
59
Hyperemesis Gravidarum Treatment
  • Control vomiting
  • Correct dehydration
  • Restore electrolyte balance
  • Maintain adequate nutrition

60
Hyperemesis Gravidarum Nursing Care
  • Assess the amount and character of further emesis
  • Assess intake and output and weight.
  • Assess fetal heart rate
  • Assess maternal vital signs
  • Observe for evidence of jaundice or bleeding
  • Assess the womans emotional state

61
Nursing Care of Clients with PROM
  • Determine duration of PROM
  • Assess gestational age
  • Observe for signs and symptoms of infection
  • Assess hydration status
  • Assess fetal status
  • Assess childbirth preparation and coping

62
Nursing Clients with PROM (contd)
  • Encourage resting on left side
  • Provide comfort measures
  • Provide education

63
Nursing Care of Clients with Preterm Labor
  • Identify risk for preterm labor
  • Assess change in risk status for preterm labor
  • Assess educational needs of the woman and her
    loved ones
  • Assess the womans responses to medical and
    nursing intervention
  • Teach about the importance of recognizing the
    onset of labor

64
Signs and Symptoms of Preterm Labor
  • Uterine contractions occurring every 10 minutes
    or less
  • Mild menstrual like cramps felt low in the
    adbomen
  • Constant or intermittent feeling of pelvic
    pressure
  • Rupture of membranes
  • Low, dull backache, which may be constant or
    intermittent

65
Signs and Symptoms of Preterm Labor (contd)
  • A change in vaginal discharge
  • Abdominal cramping with or without diarrhea

66
Classification of Hypertension in Pregnancy
  • Preeclampsia-eclampsia
  • Chronic hypertension
  • Chronic hypertension with superimposed
    preeclampsia
  • Gestational hypertension

67
Chronic Hypertension in Pregnancy
  • Hypertension before 20 weeks without proteinurea
    or stable proteinurea
  • At a higher risk for adverse outcomes
  • At risk for development of pre-eclampsia

68
Chronic Hypertension
  • If target organ damage present, pregnancy can
    exacerbate the condition
  • Lifestyle modifications
  • - Activity restrictions
  • - Weight reduction
  • - Sodium restriction
  • - ETOH and tobacco strongly discouraged

69
Plan of Care Chronic Hypertension in Pregnancy
  • Medications can safely be withheld in patients
  • Without target organ damage
  • Blood pressure less than 150-160 mmHg systolic
    and 100-110 diastolic

70
Pharmacological management Chronic HTN in
Pregnancy
  • Methyldopa (Aldomet) preferred alpha-2 adrenergic
    agonist
  • Labetalol (normodyne, Trandate) beta blocker
  • Diuretic, calcium antagonists, other beta
    blockers?
  • ACE (angiotension converting enzyme) inhibitors
    are contraindicated in pregnancy IUGR,
    oligohydramnios, neonatal renal failure, and
    neonatal death
  • ARB (angiotension receptor blockers)not
    researched in pregnancy but probably
    contraindicated

71
Labatalol
  • Baby at risk for transient hypotension and
    hypogylcemia if mom on labatalol
  • No labatalol to clients with asthma or first
    degree heart block

72
Fetal Assessment
  • Fetal growth restriction
  • Ultrasound _at_ 18-20 weeks, 28-32 weeks as needed
    thereafter
  • NST or biophysical profile if growth restricted

73
Preeclampsia-eclampsia
  • Increased blood pressure AND proteinurea
  • Highly suspected if increased BP and headache,
    blurred vision, abdominal pain, low platelets
    and/or abnormal liver enzymes

74
MAP
  • Mean Arterial Pressure average of systolic and
    diastolic blood pressure readings
  • SBP DBP DBP
  • 3
  • ACOG states hypertension exists when there is an
    increase in the MAP of 20 mmHg, and if no
    baselines are known, a MAP of 105 mmHg is used
  • Two readings 4-6 hours apart

75
Hypertension in Pregnancy
  • Hypertension complicates 5-7 of all pregnancies
  • One-half to two-thirds have preeclampsia or
    eclampsia
  • Hypertension is a leading cause of maternal and
    infant morbidity and mortality

76
Normal Adaptations to Pregnancy
  • Increased blood plasma volume
  • Vasodilation
  • Decreased systemic vascular resistance
  • Elevated cardiac output
  • Decreased colloid osmotic pressure

77
Preeclamptic Changes in Pregnancy
  • Renal lesions are present, especially in
    nulliparous women (85)
  • Arteriolar vasospasm diminishes the diameter of
    the blood vessels which impedes blood flow to
    organs and raises blood pressure (perfusion to
    placenta, kidneys, liver, and brain can be
    diminished by 40-60)

78
Etiology of Hypertension
  • Vasospasms are one of the underlying mechanisms
    for the signs and symptoms of preeclampsia
  • Endothelial damage (from decreased placental
    perfusion) contributes to preeclampsia
  • With endothelial damage, arteriolar vasospasm may
    contribute to increased capillary permeability.
    This increases edema and decreases intravascular
    volume

79
Other Suspected Causes
  • The presence of foreign protein (placenta or
    fetus) may trigger an immunologic response
  • This is supported by
  • - the incidence of preeclampsia in first-time
    mothers (first exposure to fetal tissue)
  • - women pregnant by a new partner (different
    genetic material)

80
Pulmonary Preeclamptic Changes
  • At risk for development of pulmonary edema
  • Pulmonary capillaries susceptible to fluid
    leakage across membranes due to endothelial
    damage
  • Left ventricular failure from increased afterload
    leading to backup of fluid in pulmonary bed

81
Renal Preeclamptic Changes
  • Reduced kidney perfusion decreases the glomerular
    filtration rate which lead to degenerative
    changes and oliguria
  • Protein is lost in the urine, sodium and water
    are retained
  • Fluid moves out of the intravascular compartment
    resulting in increased blood viscosity and tissue
    edema

82
Vascular Preeclamptic Changes
  • Hematocrit level rises as fluid leaves the cells
  • Blood volume may fall to or below prepregnancy
    levels severe edema develops and weight gain is
    seen
  • Decreased liver perfusion causes impaired
    function. Epigastric pain or RUQ pain

83
More Preeclamptic Changes
  • Arteriolar vasospasms with decreased blood
    perfusion to the retina causes visual changes
    such as blind spots and blurring
  • CNS changes caused by spasms as well as edema
    include headache, hyperreflexia, positive ankle
    clonus, and occasionally the development of
    eclampsia

84
Characteristics of Preeclampsia
  • Maternal vasospasm
  • Decreased perfusion to virtually all organs
  • Decrease in plasma volume
  • Activation of the coagulation cascade
  • Alterations in glomerular capillary endothelium
  • Edema

85
Characteristics of Preeclampsia
  • Increased viscosity of the blood
  • Hyperreflexia
  • Headache
  • Subcapsular hematoma of the liver

86
A In a normal pregnancy, the passive quality of
the spiral arteries permits increased blood flow
to the placenta.
87
B In preeclampsia, vasoconstriction of the
myometrial segment of the spiral arteries occurs.
88
What is the possible end result?
  • Heart failure, caused by circulatory collapse and
    shock
  • Pulmonary edema, associated with severe
    generalized edema (weak, rapid pulse, lowered
    blood pressure, crackles)
  • HELLP Syndrome Multisystem disease in which
    hemolysis, elevated liver enzymes and low
    platelets are present
  • Disseminated Intravascular Coagulation (DIC)
  • Clotting factors are consumed by excess fluid,
    generalized bleeding occurs. Thrombocytopenia

89
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90
Differential Diagnosis
  • BP of gt 160 systolic or gt 110 diastolic
  • Proteinurea of 1-2 on 2 dipsticks at least 4
    hours apart or .3 grams or more in 24 hours
  • Increased serum creatinine gt 1.2 unless prior
    elevation
  • Platelet count less than 100,000
  • Elevated ALT or AST
  • Persistent headache or visual changes
  • Persistent epigastric pain, nausea and vomiting

91
Labs
  • Hgb Hct hemoconcentration supports dx of
    preeclamsia and is an indicator of severity.
    Values may be decreased, however, if hemolysis
    accompanies the disease
  • Platelets thrombocytopenia suggests severe
    preeclamsia
  • Quantification of protein excretion if
    proteinurea should consider preeclamsia
  • Serum creatinine abnormal rising levels
    especially in conjunction with oligurea
    (thickening of the renal arterioles)
  • Serum uric acid increases as urate clearance
    decreases due to enlargement of glomerular
    endothelial cells and occlusions of capillary
    lumen
  • Serum albumin hypoalbuminemia indicates extent
    of endothelial leak
  • Coagulation profile coagulopathy including
    thrombocytopenia

92
Specific Labs
  • Preeclampsia HELLP
  • Hctgt35 Hemolysis-burr
  • Uric Acid gt 4.5mg cells present
  • BUN gt 10mg/dl bili 1.2mg/d
  • Plt lt150,000 SGOT gt72 U/L
  • SGOT gt 41 U/L SGPT gt 50 U/L
  • SGPT gt 30 U/L Plateletslt100,000

93
Hypertensive Effects on Fetus
  • Small for gestational age
  • Fetal hypoxia
  • Death related to abruption
  • Prematurity

94
Home Management
  • Monitoring for signs and symptoms of worsening
    condition
  • Fetal movement counts
  • Frequent rest in the left lateral position
  • Monitoring of blood pressure, weight, and urine
    protein daily
  • NST
  • Laboratory testing

95
Management of Severe Preeclampsia
  • Bed rest
  • High-protein, moderate-sodium diet
  • Treatment with magnesium sulfate
  • Corticosteroids
  • Fluid and electrolyte replacement
  • Antihypertensive therapy

96
Fetal Indications for Delivery
  • Severe IUGR
  • Nonreassuring fetal surveillance
  • oligohydramnios

97
Maternal Indications for Delivery
  • Gestational age of 38 weeks or greater
  • Platelet count below 100K
  • Progressive deterioration of hepatic function
  • Progressive deterioration of renal function
  • Suspected placental abruption
  • Persistent severe headache or visual changes
  • Persistent severe epigastric pain, nausea, or
    vomiting
  • eclampsia

98
Plan of Care for the Preeclamptic
  • Complete bedrest
  • Left lying position-increases kidney glomerular
    function and urine output
  • Provide darkened quiet room
  • Limit visitation
  • Fluid restriction (125-150ml/hr)
  • Seizure precautions
  • Magnesium sulfate
  • Antihypertensives

99
Preeclampsia Assessment
  • Edema
  • DTRs and clonus
  • Assess fluid balance-strict I O
  • Breath sounds (pulmonary edema)
  • Vital signs BP, respiratory rate SaO2
  • LOC
  • c/o HA or visual disturbances
  • Proteinurea
  • Epigastric pain

100
Edema
  • 1 edema is minimal (2mm) at pedal and pretibial
    sites
  • 2 (4mm) edema of lower extrmities is marked
  • 3 (6mm) edema is evident in hands, face, lower
    abdominal wall and sacrum
  • 4 (8mm) generalized massive edema is evident
    including ascites from accumulaton of fluid in
    the peritoneal cavity

101
Assessment of CNS Changes
  • DTRs and Clonus
  • DTRs 0-4 patellar and brachial
  • 0no response
  • 1low normal
  • 2average
  • 3brisk
  • 4hyperactive

102
Clonus
  • Extreme hyperreflexia
  • Involuntary oscillations that may be seen between
    flexion and extension when continuous pressure is
    applied to the sole of the foot
  • Counted in beats

103
Plan of Care for the Preeclamptic
  • Magnesium Sulfate used to prevent or control
    seizures-it is a CNS depressant and smooth muscle
    relaxant-increases blood flow to the fetus
  • It does not treat the BP
  • Interferes with the release of acetylcholine at
    the synapses, decreases neuromuscular irritability

104
Magnesium Sulfate
  • Loading dose 4-6 grams over 15-30 minutes
  • Maintenance dose 1-2 grams/hour
  • Therapeutic levels 4.8-9.6 mg/dl
  • Always IVPB to mainline
  • Calcium gluconate available as antidate

105
Renal Insufficiency
  • Magnesium sulfate is hazardous to women with
    severe renal failure and maintenance dose must be
    reduced

106
Assessment of Patients on Magnesium Sulfate
  • BP, pulse, and respiratory status should be
    monitored at least every 5 minutes with the
    loading dose, and every 15 minutes while on
    maintenance
  • Continued the first 24 hours postpartum to
    prevent seizures
  • Monitor I O 30ml/hr
  • Serum levels every 4-6 hours therapeutic
    4.8-9.6 mg/dl

107
Side Effects of Mag Sulfate
  • Flushing
  • Sweating
  • Thirst
  • Drying mucous membranes
  • Depression of reflexes
  • Muscle flaccidity
  • Nausea
  • Blurred visoin
  • HA
  • tachycardia

108
Clinicial Manifestations of Hypermagnesemia
  • Weakness
  • Paresthesias
  • Dcreased deep tendon reflexes
  • Lethargy, confusion, disorientation
  • Hypoventilatoin
  • Seizures
  • Paralysis
  • Bradyarrythmias
  • Heart block
  • Decreased cardiac contractility
  • Impaired protein synthesis
  • Decreased skeletal mineralization
  • Hepatic dysfunction

109
Calcium Gluconate
  • Antidote for mag sulfate
  • 1 g of 10 calcium gluconate is administered slow
    IV push over 3 minutes and repeated every hour
    until signs and sxs of toxicity have been
    resolved
  • Should be kept at the bedside

110
Control of BP
  • Antihypertensives may be needed to lower the
    diastolic pressure
  • This reduces maternal mortality and morbidity
    associated with left ventricular failure and
    cerebral hemorrhage
  • Placental perfusion is controlled by maternal
    blood pressure, drug must be calibrated carefully

111
Antihypertensives
  • If BP reaches 150/100 mmHg or higher
  • Labatalol (alpha/beta adrenergic blocker)
  • Begin with 20mg IVP slowly over 2 minutes
  • Or continuous infusion of 1mg/kg can be used
  • May double dose up to 80 mg every 15-20 minutes
  • Maximum dose 220mg
  • Apresoline (vasodilator)
  • Begin with 5-20 mg infused over 2-4 minutes
  • May be repeated every 20-30 minutes
  • If no success by 20 mg IV or 30 mg IM try another
    drug

112
Eclampsia
  • Derives from the Greek word meaning like a flash
    of lightening
  • a condition that seems to strike out of the blue
  • 75 of the time it occurs intrapartum

113
Eclampsia
  • Characterized by seizures or coma
  • Is a major hazard with poor outcomes in
  • - gestations of less than 28 weeks
  • - mothers older than 35 years of age
  • - multigravidas
  • - chronic HTN, renal disease or diabetes

114
Eclampsia
  • Rare in the Western world because doctors can
    diagnose the condition in its earliest phase
    (preeclampsia) and they are constantly on the
    alert for the warning signs
  • Earliest signs drowsiness, HA, dimness of
    vision, rising BP, protein in the urine, edema,
    RUQ pain

115
Etiology
  • Cerebral vasospasm, hemorrhage or edema, platelet
    and fibrin clots occlude vasculature leading to
    seizure
  • Blood vessels in the uterus go into spasm cutting
    blood flow to the baby
  • Spasms lead to kidney failure
  • Tissues become water-logged because of fluid
    retention
  • Hemorrhages happen in the liver
  • Brain oxygen levels are lowered causing
    heightened brain sensitivity which shows as
    seizures

116
Signs and Symptoms of Impending Seizures
  • Extreme hypertension 200/140 not uncommon
  • Hyperreflexia
  • 4 proteinurea
  • Generalized marked edema
  • Severe headache with or without visual
    distrubances

117
Management of Care During a Seizure
  • CALL FOR HELP!
  • Immediate care Take care of the mother first
  • -patent airway
  • -adequate oxygenation
  • -turn on side to prevent aspiration
  • Magnesium Sulfate administration
  • Assessment of the fetus, birth if threatened
  • Steroid administration if fetal lungs are not
    mature

118
PNEUMONIC
  • S safety
  • E establish airway
  • I IV bolus
  • Z zealous observation
  • U uterine activity
  • R rapid resuscitation
  • E evaluate fetus

119
Postictal State
  • Central venous pressure monitoring
  • Establish second indwelling catheter
  • Blood glucose level to rule out hypogylcemia due
    to liver not functioning properly
  • Blood should be available for emergency infusion
    due to abruptio
  • Do not leave patient alone

120
REMEMBER!!!
  • All medications and therapy are merely temporary
    measures
  • Delivery is the only cure

121
Signs and Symptoms of Eclampsia
  • Scotomata
  • Blurred vision
  • Epigastric pain
  • Vomiting
  • Persistent or severe headache
  • Neurologic hyperactivity Pulmonary edema
  • Cyanosis

122
Management of Eclampsia
  • Assess characteristics of seizure
  • Assess status of the fetus
  • Assess for signs of placental abruption
  • Maintain airway and oxygenation
  • Position on side to avoid aspiration
  • Suction to keep the airway clear

123
Management of Eclampsia (contd)
  • To prevent injury, raise padded side rails
  • Administer magnesium sulfate

124
Postpartum Management
  • Symptoms usually resolve within 48 hours of birth
  • Lab abnormalities usually resolve from 72-96
    hours after birth
  • Careful assessment continues, mag sulfate may
    continue to be infused for 12-48 hours after the
    birth
  • Bleeding must be assessed

125
Hemorrhage Hypertension
  • NO Methergine
  • Causes vasospasm and increases blood pressure
  • CONTRAINDICATED in pts with HTN
  • Use hemabate or cytotec for PPH

126
Comparison of Risk Factors for HELLP Syndrome and
Preeclampsia
  • HELLP Preeclampsia
  • Multiparous Nulliparous
  • Maternal age gt25 Maternal agelt20
  • White or gt45
  • Hx of poor preg Family hx
  • Outcome Poor PNC

  • Diabetes
  • Chronic
    HTN

  • Multiple gestation

127
HELLP
  • Hemolysis, Elevated liver enzymes, Low platelet
    count
  • Prevalence is higher among older, white,
    multiparous women
  • Carries a mortality rate of 2-24
  • Occurs in 4-12 of severe preeclampsia

128
DX
  • Platelet lt 100,000
  • Liver enzymes AST ALT elevated
  • Evidence of intravascular hemolysis must be
    present

129
Complications of HELLP
  • Renal failure
  • Pulmonary edema
  • Ruptured liver hematoma
  • DIC
  • Abruptio placenta
  • Fetal death
  • Perinatal asphyxia
  • Maternal death

130
Sx of HELLP
  • Epigastric pain
  • Mailaise
  • Nausea and vomiting
  • Mild jaundice often noted
  • Sound like the flu?

131
DIC
  • Prothrombin time, partial thromboplastin time and
    fibrinogenlevels are normal in patients with
    HELLP
  • In a patient with a plasma fibrinogen level of
    less than 300 mg/dL, DIC should be suspected,
    especially if other laboratory abnormalities are
    also present
  • Oozing from venipuncture sited, hemorrhage,
    uterine atony

132
DIC
  • Systemic thrombohemorrhagic disorder involving
    the generation of intravascular fibrin and the
    consumption of procoagulants and platelets
  • Causes in pregnancy abruptio placenta, IUFD with
    retained dead fetus, AFE, endotoxin sepsis,
    preeclampsia with HELLP and massive transfusion

133
TX of DIC
  • Replacement of volume, blood products, and
    coagulation components
  • Cardiovascular and respiratory support
  • Elimination of underlying triggering mechanism
  • Anticoagulation
  • Replace blood products as indicated-packed RBCs,
    platelets, FFP, cryo
  • Antithrombin III concentrate
  • Hematology, transfusionist, critical care
    consultants.

134
Treatment for HELLP
  • Delivery is the only cure
  • Antenatal administration of dexamethasone
    (Decadron) 10 mg IV every 12 hours
  • Mag Sulfate bolus of 4-6 g as a 20 soln then
    mainenance of 2 g /hr
  • Antihypertensive therapy should be initiated if
    BP gt 160/110

135
Rh Incompatibility
  • Rh mother, Rh fetus
  • Maternal IgG antibodies produced
  • Hemolysis of fetal red blood cells
  • Rapid production of erythroblasts
  • Hyperbilirubinemia

136
Administration of Rh Immune Globulin
  • After birth of an Rh infant
  • After spontaneous or induced abortion
  • After ectopic pregnancy
  • After invasive procedures during pregnancy
  • After maternal trauma

137
ABO Incompatibility
  • Mom is type O
  • Infant is type A or B
  • Maternal serum antibodies are present in serum
  • Hemolysis of fetal red blood cells

138
Surgery During Pregnancy
  • Incidence of spontaneous abortion is increased in
    first trimester
  • Insert nasogastric tube prior to surgery
  • Insert indwelling catheter
  • Encourage patient to use support stockings
  • Assess fetal heart tones
  • Position to maximize utero-placental circulation

139
Trauma During Pregnancy
  • Greater volume of blood loss before signs of
    shock
  • More susceptible to hypoxemia with apnea
  • Increased risk of thrombosis
  • DIC
  • Traumatic separation of placenta
  • Premature labor

140
Battering During Pregnancy
  • Psychological distress
  • Loss of pregnancy
  • Preterm labor
  • Low-birth-weight infants
  • Fetal death
  • Increased risk of STIs

141
Perinatal Infections
  • Toxoplasmosis
  • Rubella
  • Cytomegalovirus
  • Herpes simplex virus
  • Group B streptococcus
  • Human B-19 parvovirus

142
Fetal Risks Toxoplasmosis
  • Retinochoroiditis
  • Convulsions
  • Coma
  • Microcephaly
  • Hydrocephalus

143
Fetal Risks Rubella
  • Congenital cataracts
  • Sensorineural deafness
  • Congenital heart defects

144
Fetal Risks Chlamydia
  • Neurologic complications
  • Anemia
  • Hyperbilirubinemia
  • Thrombocytopenia
  • Hepatosplenomegaly
  • SGA

145
Fetal Risks Herpes
  • Preterm labor
  • Intrauterine growth restriction
  • Neonatal infection

146
Fetal Risks GBS
  • Respiratory distress or pneumonia
  • Apnea
  • Shock
  • Meningitis
  • Long-term neurologic complications

147
Fetal Risks Human B-19 Parvovirus
  • Spontaneous abortion
  • Fetal hydrops
  • Stillbirth
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